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Chest xray pattern Part 1 Year 2 Class.pptx
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- 2. OUTLINE PATTERN RECOGNITION OFCHEST PATHOLOGY (X-RAY) • LUNG Increased density Decreased density • MEDIASTINUM • PLEURA & EXTRATHORACIC TUMOUR vs INFECTION
- 3. Increased density (opacities) • Alveolar (consolidation) •Interstitial • Atelectasis (collapse) • Nodule or mass Decreased density (lucencies) • Cavitation • Cyst • Emphysema LUNG ABNORMALITIES ON CHEST X-RAY
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- 5. ALVEOLAR (CONSOLIDATION) • Resultsfrom pathologic process that fills the alveoli with fluid, pus, blood, cells (including tumor cells) or other substances. • General features on chest x-ray show ill-defined, fluffy, cottonwool-like appearance of airspace opacification causing obscuration of pulmonary vessels and air bronchograms.
- 6. • Air bronchogram air-filledbronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white).
- 9. LOBAR CONSOLIDATION • Resultsfrom disease that starts in the periphery and spreads from one alveolus to another through the pores of Kohn. • At the borders of the disease some alveoli will be involved, while others are not, creating ill-defined borders. • As the disease reaches a fissure, this will result in a sharp delineation, since consolidation will not cross a fissure (limited by visceral pleura).
- 11. BULGING FISSURE SIGN •Refers to lobar consolidation where the affected portion of the lung is expanded causing displacement of the adjacent fissure. • Classically, it has been described in right upper lobe (RUL) consolidation secondary to Klebsiella pneumonia. • Other causes include: • Infective (Strep. pneumoniae, Pseudomonas aeruginosa, Staph. aureus) • Lung adenocarcinoma • Lung abscess • Pulmonary haemorrhage
- 12. DIFFUSE CONSOLIDATION • Progressionof multifocal opacities that coalesce produce diffuse consolidation. • Does not cross fissure.
- 13. BATWING CONSOLIDATION • Bilateralperihilar distribution of consolidation. • The sparing of the periphery of the lung is attributed to a better lymphatic drainage in this area. • Most typical of pulmonary oedema, both cardiogenic and non-cardiogenic. • Sometimes it is seen in pneumonias.
- 14. ATELECTASIS (COLLAPSE) • Resultof loss of air in a lung or part of the lung with subsequent volume loss due to airway obstruction or compression of the lung by pleural fluid or a pneumothorax. • General features on chest x-ray: • Sharply-defined opacity obscuring vessels without air-bronchogram. • Volume loss resulting in displacement of diaphragm, fissures, hila or mediastinum. Passive Loss of intrapleural negative pressure causing lung to be no longer held against chest wall. Obstructive Occurs as a result of complete obstruction of an airway. No new air can enter, any air that is already there is eventually absorbed into the pulmonary capillary system.
- 15. Compressive atelectasis • occursas a result of any thoracic space-occupying lesion compressing the lung and forcing air out of the alveoli Cicatrization atelectasis • occurs as a result of scarring or fibrosis that reduces lung expansion • common aetiologies include granulomatous disease, necrotizing pneumonia and radiation fibrosis
- 16. Right upper lobecollapse • increased density in the upper medial aspect of the right hemithorax • elevation and/or superior bowing of the horizontal fissure • loss of the normal right medial cardio-mediastinal contour • elevation of the right hilum • rotation of the bronchus intermedius laterally, appearing more horizontal than usual • hyperinflation of the right middle and lower lobe result in increased translucency of the mid and lower parts of the right lung • right juxtaphrenic peak (Kattan sign)
- 17. GOLDEN S SIGN •Typically seen with right upper lobe collapse. • Created by a central mass obstructing the upper lobe bronchus and should raise suspicion of a primary bronchogenic carcinoma. • Can also be caused by other central masses, such as metastasis, primary mediastinal tumour, or enlarged lymph nodes.
- 18. Right middle lobecollapse • right mid to lower zone air space opacification (which can be subtle) • the normal horizontal fissure is no longer visible (as it rotates inferiorly rendering it non- tangential to the x-ray beam) • obscuration of the right heart border • lateral projection: a triangular opacity in the anterior aspect of the chest overlying the cardiac shadow.
- 19. Right lower lobecollapse • triangular opacity at the right lower zone (usually medially) with the apex pointing towards the right hilum • obscuration of the medial aspect of the dome of right hemidiaphragm • inferior displacement of the right hilum • descending interlobar pulmonary artery is not visible • preservation of a clear right heart border, which is contacted by the right middle lobe • inferior displacement of the horizontal fissure
- 20. Left upper lobecollapse • Collapsed left upper lobe appears as a hazy or veiling opacity extending out from the left hilum and fading out inferiorly • Obscuration of parts of the normal cardiomediastinal contour particularly where the lingular segments abuts the left heart border • Luftsichel sign the hyperexpanded superior segment of the left lower lobe insinuates between the left upper lobe and the superior mediastinum, sharply silhouetting the aortic arch resulting in a sickle-shaped lucency medially • The left hilum is drawn upwards
- 21. Left lower lobecollapse • triangular left lower zone opacification (usually medially, retrocardiac) with the apex pointing towards the left hilum • edge of the collapsed lung may create a 'double cardiac contour' • inferior displacement of the left hilum • Flat waist sign: flattening of the left heart border • obscuration of the left hemidiaphragm • obscuration of the descending aorta • preservation of a clear left heart border, which is contacted by the lingular segments of the left upper lobe • inferior displacement of the oblique fissure • descending interlobar pulmonary artery is not visible
- 22. Plate atelectasis • Focalarea of subsegmental atelectasis that has a linear shape. • May appear to be horizontal, oblique or perpendicular line of 1-3 mm in thickness. • Frequently seen in patients in ICU due to poor ventilation and postoperative patients. • In most cases these findings have no clinical significance and are seen in smokers and elderly.
- 23. SILHOUETTE SIGN • Pathologicalloss of two adjacent structures differentiation (i.e. lung and mediastinal border). • It denotes that a mediastinal border can only be obscured by pathology which is in direct anatomical contact. • Useful in localising areas of airspace opacities, atelectasis or mass within the lung. Loss of silhouette: • right paratracheal stripe: right upper lobe • right heart border: right middle lobe or medial right lower lobe • right hemidiaphragm: right lower lobe • aortic knuckle: left upper lobe • left heart border: lingular segments of the left upper lobe • left hemidiaphragm or descending aorta: left lower lobe
- 24. INTERSTITIAL OPACITY • Reticularopacities or small nodules due to involvement of the supporting tissue of the lung parenchyma (interstitium). • Results from thickening of any of the interstitial compartments by blood, water, tumor, cells, fibrous disease or any combination thereof. • Can be reticular, reticulonodular, or linear where the predominant pattern is a result of the underlying pathological process.
- 25. Reticular interstitial opacity •Complex network of curvilinear opacities that usually involved the lung diffusely. • Can be subdivided by their size based on the size of the lucent spaces created by the intersection of lines.
- 26. • Fine "ground-glass"(1-2 mm): seen in processes that thicken the pulmonary interstitium to produce a fine network of lines, e.g. interstitial pulmonary oedema • Medium "honeycombing" (3-10 mm): commonly seen in pulmonary fibrosis with involvement of the parenchymal and peripheral interstitium • Coarse (>10 mm): cystic spaces caused by parenchymal destruction, e.g. usual interstitial pneumonia, pulmonary sarcoidosis, pulmonary Langerhans cell histiocytosis.
- 28. Reticulonodular interstitial opacity •Overlap of reticular shadows or by the presence of reticular shadowing and pulmonary nodules. • Relatively common appearance on a chest radiograph, very few diseases are confirmed to show this pattern pathologically: silicosis pulmonary sarcoidosis berylliosis lymphangitic carcinomatosis hepatopulmonary syndrome - basal pneumocystis pneumonia bronchocentric granulomatosis pulmonary Langerhans cell histiocystosis lymphocytic interstitial pneumonitis Erdheim-Chester disease
- 29. Linear interstitial opacity •Seen in processes that thicken the axial (bronchovascular) interstitium or the peripheral pulmonary interstitium. • Axial: diffuse thickening along the bronchovascular tree seen as parallel opacities radiating from the hila (seen transversely) or peribronchial cuffing (seen en face). • Peripheral: thickening of the peripheral interstitium (either medially or laterally) produces Kerley lines. • Axial interstitial thickening is difficult to distinguish from airways disease that result in bronchial wall thickening, (e.g. bronchiectasis, asthma) and most often seen in interstitial pulmonary oedema.
- 30. Kerley lines (septallines) • Prominent interlobular septa in the pulmonary interstitium because of lymphatic engorgement or oedema of the connective tissues of the interlobular septa. • Usually occur when pulmonary capillary wedge pressure reaches 20-25 mmHg. Causes • pulmonary oedema • neoplasm • lymphangitic spread of cancer • breast cancer • colon cancer • stomach cancer • pancreatic cancer • lung cancer • lymphoma • pulmonary lymphoma • pneumonia • viral pneumonia • mycoplasma pneumonia • Pneumocystis pneumonia • interstitial pulmonary fibrosis • pneumoconiosis • sarcoidosis
- 31. Kerley A • 2-6cm long oblique lines that are <1 mm thick and course towards the hila. • Represents thickening of the interlobular septa that contain lymphatic connections between the perivenous and bronchoarterial lymphatics deep within the lung parenchyma. • On chest radiographs they are seen to cross normal vascular markings and extend radially from the hilum to the upper lobes.
- 32. Kerley B • Thinlines 1-2 cm in length in the periphery of the lung(s). • Represent thickened subpleural interlobular septa and are usually seen at the lung bases. • Perpendicular to the pleural surface and extend out to it. *Kerley D lines are exactly the same as Kerley B lines, except that they are seen on lateral chest radiographs in the retrosternal air gap.
- 33. Kerley C • shortlines which do not reach the pleura and do not course radially away from the hila (neither A nor B).
- 34. NODULES OR MASSES Suggestedrisk factors to consider include older age, heavy smoking, irregular or spiculated margins, and upper lobe location. • A discrete, well- marginated, rounded opacity less than or equal to 3 cm in diameter. • Lesions smaller than 3 cm are most commonly benign granulomas, while lesions larger than 3 cm are treated as malignancies until proven otherwise and are called masses.
- 35. Metastases • Typically appearas peripheral, rounded nodules of variable size, scattered throughout both lungs predominantly lower lobes and subpleural.
- 36. Mucoid impaction • Canmimic the appearance of lung nodules or a mass. • Commonly seen in patients with bronchiectasis, as in cystic fibrosis (CF), allergic bronchopulmonary aspergillosis (ABPA) and bronchial atresia. • ‘Finger-in-glove’ appearance: mucus in dilated bronchi looks like fingers in glove.
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- 39. Cavity • Frequently arisewithin a mass or an area of consolidation as a result of necrosis.
- 40. Monod sign • Gasthat surrounds a mycetoma (most commonly an aspergilloma) in a pre- existing pulmonary cavity. • Gas around the mycetoma is often crescent-shaped and hence, the term air crescent sign is used interchangeably.
- 41. Pneumatocele • Majority ofpneumatoceles occur as a result of pneumonia, most common causative agents being S. aureus.
- 42. Bulla • Focal regionsof emphysema with no discernible wall which measure more than 1 or 2 cm in diameter. • Often subpleural in location and are typically larger in the apices
- 43. Emphysema • Abnormal permanentenlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of the alveolar wall and without obvious fibrosis. • Chest x-ray does not image emphysema directly, but indirect signs • hyperinflation • paucity of blood vessels • pulmonary arterial hypertension features (pruning of peripheral vessels, increased calibre of central arteries, right ventricular enlargement)
- 44. MEDIASTINUM Mediastinal division • Superior:Above a line drawn from lower border of T4 to sternal angle. • Anterior: Between anterior part of the pericardium and posterior to the sternum. • Middle: Occupied by heart and its vessels . • Posterior: Between posterior part of the heart and thoracic spine, extends down behind posterior part of diaphragm as it descends down.
- 45. Mediastinal mass • Amediastinal mass does not contain air bronchograms. • The margins with the lung will be obtuse. • Disruption of mediastinal lines (azygoesophageal recess, anterior and posterior junction lines). • There can be associated spinal, costal or sternal abnormalities.
- 46. Posterior mediastinal masses ›Cervicothoracic sign › Widening of the paravertebral stripes 4Ts
- 47. HILUM OVERLAY SIGN •To differentiate whether a hilar opacity on a frontal chest radiograph is located within the hilum or anterior/posterior to it. • Loss of normal pulmonary vessels (interlobar artery, upper lobe arteries, and left lower lobar artery) silhouette – lesion from hilum. Causes of these opacities include middle mediastinal tumours, hilar adenopathy, pericardial effusion, vascular enlargement, and cardiac enlargement. • Preserved hilar vessels implies the cause of the opacity is not in contact with the hilum and is, therefore, either anterior or posterior to it. Most of these opacities are masses in the anterior mediastinum.
- 48. CERVICOTHORACIC SIGN • Variationof the silhouette sign on frontal chest radiography used to determine whether a superior (para)mediastinal soft tissue mass is anterior or posterior to the trachea. • As the anterior mediastinum ends at the level of the clavicles, the upper border of an anterior mediastinal lesion cannot be visualised extending above the clavicles. – Positive cervicothoracic sign. • Any lesions with a discernible upper border above clavicular level must be located posteriorly in the chest (posterior mediastinum). – Negative cervicothoracic sign.
- 49. PLEURA • Serous membranecomposed of mesothelial cells and loose connective tissue. • Divided into parietal pleura and visceral pleura. • Contains up to 5 ml of fluid within the two layers and normally not separated. • No communication between the right and left pleural cavities.
- 50. Pleural opacities • Themost common condition is pleural thickening. • Differentiation between pulmonary and extrapleural lesion is crucial in making appropriate diagnosis. Pulmonary lesion usually have acute angles with the chest wall, are centered in the lung, and engulf the pulmonary vasculature. A pleural opacity shows obtuse angles with the lateral chest wall with tapered margins, displaces the pulmonary vasculature, changes its location on respiration, and may show incomplete border sign on chest radiograph Extrapleural lesions may arise from extrapleural fat, ribs, intercostal muscles, and neurovascular bundle; cause erosion of ribs.
- 53. Pleural effusion • Presenceof fluid in the pleural space. • It takes about 200-300 ml of fluid before it comes visible on an CXR. About 5 litres of pleural fluid are present when there is total opacification of the hemithorax. Transudate Exudate Increased in hydrostatic pressure/ decreased capillary oncotic pressure. Seen in cases e.g.: • cardia failure • nephrotic syndrome • cirrhosis • trauma • asbestos exposure • post coronary artery bypass grafting: small unilateral left- sided pleural effusion can be common • certain medications: dasatinib Increased in permeability of the microcirculation or alteration in the pleural space drainage to lymph nodes. Seen in cases e.g.: • bronchial carcinoma • secondary (metastatic) malignancy • pulmonary embolism and infarction • pneumonia • tuberculosis • mesothelioma • rheumatoid arthritis • systemic lupus erythematosus (SLE) • lymphoma
- 54. • Features onplain radiograph (erect) blunting of the costophrenic angle blunting of the cardiophrenic angle fluid within the horizontal or oblique fissures eventually, a meniscus will be seen, laterally and gently sloping medially (however not visible in case of hydropneumothorax ) with large volume effusions, mediastinal shift occurs away from the effusion (however, if coexistent collapse dominates then mediastinal shift may occur towards the effusion)
- 55. • Features onplain radiograph (supine) • no meniscus, and only a veil-like increased density of the hemithorax may be visible as the fluid collects posteriorly
- 56. SUBPULMONIC EFFUSION • Pleuraleffusion that collects between the lung base and diaphragm. • Can only be seen on erect radiograph: • apparent elevation and flattening of the diaphragm (what appears to be the diaphragm actually represents the visceral pleura, and the true diaphragm is obscured by the presence of infrapulmonary fluid) • peak of pseudodiaphragm lies lateral to the normal position • increased distance between the pseudodiaphragm and the gastric bubble (on the left).
- 57. Pleural plaques • Theyhave irregular shapes with thickened nodular edge (holly leaf appearance) and do not look like a lung masses or consolidations. • Bilateral and extensive in asbestos related pleural plaques. • Unilateral, calcified pleural plaques seen in • infection (TB) • empyema • hemorrhagic
- 58. Pneumothorax • Presence ofair in the pleural space. • Can be • primary spontaneous: no underlying lung disease • secondary spontaneous: underlying lung disease is present • iatrogenic/traumatic Primary spontaneous Secondary spontaneous Tall and thin people are more likely to develop There are well–known associations • Marfan syndrome • Ehlers-Danlos syndrome • alpha-1-antitrypsin deficiency • homocystinuria Cystic lung disease • bullae, blebs • emphysema, asthma • pneumocystis jiroveci pneumonia (PJP) • honeycombing: end-stage interstitial lung disease • lymphangiomyomatosis (LAM) • Langerhans cell histiocytosis (LCH) • cystic fibrosis Parenchymal necrosis • lung abscess, necrotic pneumonia, septic emboli, fungal disease, tuberculosis • cavitating neoplasm, metastatic osteogenic sarcoma • radiation necrosis • pulmonary infarction other • catamenial pneumothorax: recurrent spontaneous pneumothorax during menstruation, associated with endometriosis of pleura • rarely pleuroparenchymal fibroelastosis Iatrogenic/traumatic Iatrogenic: • percutaneous biopsy • barotrauma (e.g., divers), ventilator • radiofrequency (RF) ablation of lung mass • endoscopic perforation of the oesophagus • central venous catheter insertion, nasogastric tube placement Trauma: • pulmonary laceration (rib fracture) • tracheobronchial rupture • acupuncture 14,15 • oesophageal rupture
- 59. • On plainradiograph (erect) it demonstrates • visible visceral pleural edge is seen as a very thin, sharp white line • no lung markings are seen peripheral to this line • peripheral space is radiolucent compared to the adjacent lung • lung may completely collapse • subcutaneous emphysema and pneumomediastinum may also be present
- 60. • Supine projectionmay only detect 50% of the pneumothoraces. Signs include: • relative lucency of the involved hemithorax • deep, sometimes tongue-like, costophrenic sulcus: deep sulcus sign • increased sharpness of the adjacent mediastinal margin and diaphragm • increased sharpness of the cardiac borders or diaphragm • visualisation of the anterior costophrenic sulcus: double diaphragm sign • visualisation of the inferior edge of the collapsed lung above the diaphragm • depression of the ipsilateral hemidiaphragm • Shift of mediastinum away from the pneumothorax indicates tension pneumothorax.
Editor's Notes
- #10 The most common cause for lobar consolidation is pneumonia.
- #16 Kattan sign-peaked or tented appearance of a hemidiaphragm which can occur in the setting of lobar collapse or post lobectomy (lung). It is caused by retraction of the lower end of diaphragm at an inferior accessory fissure (most common 1), major fissure or inferior pulmonary ligament. It is commonly seen in collapse of the left or right upper lobes but may also be seen in middle lobe collapse.